Medical Practitioners Benefit

The Medical Practitioners Benefit provides reimbursement for a multitude of paramedical services, subject to the expense limits, exclusions, and professional certification requirements described in the Plan Document.

In order to be eligible under the Plan, some services require prescriptions (valid for one year) and may require the completion of a questionnaire prior to incurring expenses. Contact Sun Life to find out what documentation is required and what credentials the practitioner must have for their services to be covered by the Plan.

For all services under the Medical Practitioners Benefit, only services within the area of expertise of the practitioner and that require the skills of the practitioner are eligible. In addition, the practitioner must be registered, licensed, or certified to practice in the jurisdiction where service are rendered in accordance with provincial/territorial regulations.

Physician and lab fees

Eligible expenses are the reasonable and customary charges for physician’s services and laboratory services where such services are not eligible for reimbursement under the participant’s provincial or territorial health insurance plan, but where such services would be covered in one or more other provincial/territorial plans, with the following important notations:

Where only one province/territory provides reimbursement for a particular service, and that province/territory discontinues the coverage, the issue shall be subject to review by the Partners Committee as to whether coverage will also be discontinued under the Plan. Claims for such services, following cessation of provincial/territorial coverage, shall be held by the Administrator pending the decision of the Partners Committee.

Where a province/territory begins reimbursement for a particular service, claims for the service shall be held by the Administrator pending a review by the Partners Committee as to whether the service should be covered in the other provinces and territories.

Laboratory services include those services which, when ordered by and performed under the direction of a physician, provide information used in the diagnosis or treatment of disease or injury. Services include, but are not limited to, blood or other body fluid analysis, clinical pathology, radiological procedures, ultrasounds, etc.

Exclusions

No benefit is payable for:

PSA (Prostate-Specific Antigen) tests used for screening purposes. PSA tests are only eligible when used for monitoring purposes following the diagnosis of cancer.

Lab tests in private clinics

The PCA 3 urine test

Nursing services

For nursing services to be eligible for reimbursement under the Plan, they must meet several conditions. The services must be:

Provided by a private duty nurse (i.e. a nurse who practices on a private basis or who works for a nursing agency such as V.O.N.) who has graduated from a recognized school of nursing and obtained certification as a registered nurse, registered nursing assistant, registered practical nurse, licensed practical nurse, or certified nursing assistant, and is listed on the appropriate provincial/territorial registry (or who has equivalent qualifications as determined by Sun Life)

Medically necessary for the treatment of a disease or injury

Performed in the patient’s private residence

Within the nurse’s area of expertise, and they must require the skills and qualifications of a nurse

Before reimbursement can be provided for nursing services that meet these conditions, you must contact Sun Life and obtain a questionnaire to be filled out by your physician. Your physician must provide information such as the medical condition requiring the nursing care, the duties the nurse will be performing, and the length of time the nursing care will be required. Sun Life reviews requests for nursing services on a case-by-case basis to determine if they are eligible under the Plan.

Foot care costs may also be eligible if the treatment has been prescribed by a physician and the treatment is provided in the patient’s private residence by a private duty nurse as defined above.

The maximum eligible expense for nursing services is $15,000 per year (reimbursed at 80%). A physician’s prescription for nursing services is valid for one year unless otherwise approved by the Administrator.

Exclusions

No benefit is payable for:

Nursing services rendered by salaried employees of a facility where the member resides or receives treatment (such as a nursing home or hospital)

Services that do not require the specific skills and qualifications of a nurse (e.g. patient transfers, incontinence care, safety monitoring, repositioning, and assistance with daily activities such as feeding, bathing, and performing household chores)

Services of other medical practitioners

To be eligible under the Plan, the services rendered must:

be performed by a practitioner that is registered, licensed or certified—in accordance with provincial/territorial regulations—to practice in the jurisdiction where the services are rendered,

require the skills and qualifications of the practitioner,

be in the area of expertise of that practitioner.

You are encouraged to contact Sun Life prior to incurring expenses to verify that the medical practitioner has the appropriate credentials for their services to be eligible under the Plan.

Treatment for the permanent removal of excessive hair from exposed areas of the face and neck when the patient suffers from severe emotional trauma as a result of this condition.

In the case where the services are performed by an electrologist, a prescription is required from a psychiatrist or a psychologist to certify that the patient suffers from severe emotional trauma as a result of this condition.

The prescription is valid for three years. The maximum eligible expense is $20 per visit.

Services performed by acupuncturists. Acupuncture is only eligible for reimbursement when performed by a physician.

Utilisation fees for paramedical services

The Plan provides reimbursement for utilisation fees for paramedical services which are imposed by the government under the provincial/territorial health insurance plan in your province/territory of residence, where the law allows you to be reimbursed for such charges.